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Palliative cancer care - pain - Management
Which non-opioid drug should I prescribe?

  • Paracetamol and/or a nonsteroidal anti-inflammatory drug (NSAID) are recommended first line.
  • If an NSAID is appropriate and not contraindicated:
    • Ibuprofen, diclofenac, and naproxen are the NSAIDs of choice.
    • The oral route is preferred, but if this is not possible, consider alternative routes (such as rectal).
    • Consider prescribing a proton pump inhibitor with an NSAID. For more information on minimizing the risks associated with NSAID treatment, see the CKS topic on NSAIDs - prescribing issues.
  • Non-opioid adjuvant drugs may also be useful for some people with specific pain types; see Management of specific types of pain.
Basis for recommendation
  • CKS found no good-quality evidence that NSAIDs have a better benefit/harm ratio than paracetamol in cancer-related pain. Few comparative studies have examined their relative efficacy and adverse effects with long-term use, and most published data are from single-dose studies [McQuay and Moore, 1997].
    • Paracetamol: a Cochrane review examined the use of paracetamol in cancer-related pain and found insufficient trial data to make firm conclusions [McNicol et al, 2007].
    • NSAIDs: a Cochrane review assessed the effect of NSAIDs in the treatment of cancer-related pain and found that NSAIDs are effective for short-term treatment of cancer-related pain [McNicol et al, 2007]. Insufficient studies were found to make conclusions about their long-term use.
  • Diclofenac, naproxen, and ibuprofen are recommended. They are widely considered to have acceptable adverse effect profiles [CSM, 2002]. Standard NSAIDs other than ibuprofen, diclofenac, or naproxen are associated with a higher risk of gastrointestinal adverse events [Henry et al, 1996; Hernández-Diaz and Rodriguez, 2000; CSM, 2003]. Modified-release products are relatively more expensive.
  • CKS has not recommended cyclo-oxygenase 2–selective NSAIDs because there is no evidence that they offer any advantage in terms of pain control compared with standard NSAIDs [Davis et al, 2005]. If gastrointestinal safety is a concern and an NSAID is thought to be necessary, CKS recommends a standard NSAID plus a proton pump inhibitor. For more information, see the CKS topic on NSAIDs - prescribing issues.

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